Team approach for nonmedical opioid use
Authors: Mike Fillon
Journal: CA A Cancer Journal for Clinicians (2023)

Although no one disputes the efficacy of opioids for the relief of pain related to cancer and its therapies, there is alarm over nonmedical opioid use (NMOU) and its substantial adverse impacts on patients, their families, and their communities. A new study reports on an approach called Compassionate High-Alert Team (CHAT) to counteract NMOU. “Non-medical opiate use is a frequent and devastating complication for patients with advanced cancer. Patience with these conditions is distressing and time demanding for clinicians,” says study researcher Eduardo Bruera, MD, the McGraw Chair in the Department of Palliative, Rehabilitation, & Integrative Medicine at The University of Texas MD Anderson Cancer Center in Houston, Texas. “Our study found a major reduction in non-medical abuse behaviors accompanied by high adherence to the intervention among these patients.” The researchers’ main objectives were to study the feasibility and stability of a CHAT intervention and to determine how many patients 3 and 6 months after the intervention switched from “opioid non-adherent behaviors to opioid-adherent behaviors.” The study extends their earlier experience with a similar approach involving a smaller cohort with shorter follow-up (doi:10.1634/theoncologist.2017-0248). “We also sought to understand the types and frequencies of documented NMOU behaviors at baseline as well as the changes in the frequency of NMOU behaviors, pain intensity, and opioid More than half of oncology patients with nonmedical opioid use behaviors who received the Compassionate High-Alert Team (CHAT) approach and returned for follow-up were opioid adherent at 3 months, and most of them remained so after 6 months. A CHAT comprises a medical doctor, a nurse, and six other professionals, including a patient advocate. use 3 and 6 months after CHAT intervention,” the researchers wrote. A CHAT team comprises a medical doctor, a nurse, and 6 other professionals, including a patient advocate (who should be sensitive to a patient’s concerns, respond to complaints, and understands the hospital’s policies), a pharmacist, a social worker, a psychologist, security personnel (to counteract possible patient aggression), and a risk management representative (for possible legal support, advice, and recommendations). Each CHAT encounter is initiated by the physician, nurse, and at least one other team member if they suspect NMOU behaviors. After patient interviews, a medical record review, risk assessment tools, or toxicology tests, the 3 may activate the full CHAT team, which then meets to develop personalized strategies. They then meet with the patient to discuss their concerns. Explore the patient’s NMOU behavior(s) and any underlying reasons in a nonjudgmental way. Express concerns about the patient’s NMOU behavior(s) and make the patient aware of the likely consequences. Examine the patient’s readiness to change or modify behavior(s), including possible barriers to change. Explain the treatment plan and recommendations in a clear manner so that the patient understands boundaries and limitations. Afterward, the physician assesses and documents the meeting and formulates a plan for subsequent patient care. Patients then have follow-up visits every 1 to 2 weeks to determine if they are adhering to the plan. The researchers identified 130 patients via their medical records who had received the intervention at the Supportive Care Center at The University of Texas MD Anderson Cancer Center between January 1, 2014, and August 31, 2020. They recorded each subject’s age, gender, race, cancer diagnosis, cancer stage, insurance status, educational status, performance status, CAGEAID (Cut, Annoyed, Guilty, and EyeAdapted to Include Drugs) score, SOAPP (Screener and Opioid Assessment for Patients With Pain) score, MEDD (morphine equivalent daily dose), and ESAS (Edmonton Symptom Assessment System) score. All subjects were at least 18 years old, had been diagnosed with cancer, were receiving opioid therapy, and had at least one documented NMOU behavior requiring a CHAT intervention. More than half were female (58%), were White (60%), and had advanced cancer (82%). According to the researchers, 85% and 76% of the 130 patients who received a CHAT intervention at the baseline returned for follow-up 3 and 6 months after the intervention, respectively. Fifteen percent (19) and 18% (24) were considered by the researchers to be capable of returning for follow-up at 3 and 6 months, respectively, but declined to do so. The researchers found no significant differences in the clinical characteristics, including the number of NMOU behaviors, ESAS pain, MEDD, fatigue, depression, and anxiety, of the patients who returned for the 3-month follow-up in comparison with those lost to follow-up, and they concluded that this “missing-ness” was largely “ignorable.” More than half of the patients with NMOU behaviors who received CHAT and returned for follow-up were opioid adherent at 3 months, and most of them remained so after 6 months. NMOU behaviors decreased significantly (p < .001) from a median of 2 per patient at the baseline to none at both the 3 and 6 month follow-up. Although the overall MEDD was not significantly affected by the intervention, self-reported pain control improved throughout the follow-up period (p = .01). Notwithstanding these encouraging results, limitations in the study noted by the researchers include its retrospective data collection, its lack of a control group, and the fact that it was conducted at an academic cancer, whose patients and clinicians may not be typical of those in community settings. “This study presents a novel interprofessional approach to those with beginning or established NMOU behaviors,” says Judith A. Paice, PhD, RN, director of the Cancer Pain Program in the Division of Hematology– Oncology at the Feinberg School of Medicine at Northwestern University in Chicago, Illinois. Dr Paice notes that the intersection of cancer-related pain and substance use disorder is poorly understood, even as it alarmingly increases in prevalence: “Of particular concern is nonmedical opioid use [NMOU], as these agents are the foundation of cancer pain management. Few validated interventions exist when NMOU has been identified, oncology clinicians receive little training in the identification and care of those with NMOU, most palliative care programs do not have the capacity to provide this type of care, and access to specialists in substance use disorder is extremely limited.” Dr Paice says that the name of the clinical group (Compassionate HighAlert Team) speaks to its philosophy: providing empathic, personalized care designed to deliver education and support for patients and their caregivers. “The investigators provide a comprehensive roadmap with flowcharts of their processes, the role of each team member, and guides for these sometimes difficult conversations. The results are impressive, in that more than half of patients had a complete response (an absence of any events) at 3 and 6 months.” Currently, adds Dr Paice, the goal of most health care opioid stewardship programs seems to be the elimination of opioids, “which is not a humane or ethical option for most people with pain related to advanced cancer. Through this work, the authors have clearly established that safe opioid usen is feasible in oncology and that programs can be developed to address [NMOU] when it occurs.” She says that because the components of CHAT areexplicitly outlined, it allows clinicians to adapt this program to a variety of environments in cancer care. “Many of the tools employed are widely available, including risk screening instruments, prescription drug monitoring programs, and urine toxicology. More research can refine these programs, explore ideal screening tools, and determine optimal methods to deliver this intervention in different cancer populations and settings.” Dr Bruera believes that his study can serve as a model for other clinics. “All institutions that treat patients with cancer need to develop interdisciplinary teams such as the one we describe, capable of harmonizing opioid treatment with the prevention and management of NMOU.” The American Society of Clinical Oncology has several resources, notes Dr Paice, including Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline (doi:10.1200/JCO.2016.68.5206). Another excellent resource is the National Comprehensive Cancer Network Guidelines on Adult Cancer Pain (doi:10.6004/jnccn.2019.0038). Finally, the Substance Abuse and Mental Health Services Administration website (https://www.samhsa.gov/) has a treatment locator, education, grant opportunities, data, and targeted publications.